Pro and Con: The British Psychological Society Report on Psychosis

The original etymologies and current usages of the words "psychosis" and "neurosis" are confusingly topsy-turvy.

"Psychosis" literally means a disease of the soul or mind, but for more than 100 years this term has been used to describe only the severest forms of mental disorders, those that have at least partial causality in neurological (brain) malfunction.

"Neurosis" literally means a disease of the nerves, but for more than 200 years this term has been used to describe a grab bag of mostly milder mental disorders more clearly related to psychology (the mind) or to social pressures than to any neurological disease.

Recently there has been considerable controversy and confusion around how the word "psychosis" should be used, if indeed it should be used at all.

The British Psychological Society's Division of Clinical Psychology recently issued a report, "Understanding Psychosis and Schizophrenia [Why people sometimes hear voices, believe things that others find strange, or appear out of touch with reality . . . and what can help]." Edited by Anne Cooke, the report presents a psychological perspective on these experiences and questions the way we think about mental illness.

Anne will support the report, and I will critique it. Anne writes:

Our report has two main aims. Firstly, it is intended as a resource for people who have the experiences we think of as psychosis, and for their families. Secondly, we hope it will lead to significant change not only in mental health services, but also in wider society.

Our dream is that our report will contribute to a sea change in attitudes so that rather than facing prejudice, fear and discrimination, people who have these experiences will find those around them accepting, open-minded and willing to help.

The report has been written by a group of eminent clinical psychologists drawn from eight universities and the UK National Health Service, together with people who have themselves experienced psychosis.

It provides an accessible overview of the current state of knowledge, and its conclusions have profound implications both for the way we understand "mental illness" and for the future of mental health services.

Many people believe that schizophrenia is a frightening brain disease that makes people unpredictable and potentially violent, and can only be controlled by medication. However the report summarises recent research that suggests this view is false. Rather:

The problems we think of as "psychosis"—hearing voices, believing things that others find strange, or appearing out of touch with reality—can be understood in the same way as other psychological problems such as anxiety or shyness.

They are often a reaction to trauma or adversity of some kind which impacts on the way we experience and interpret the world.

They rarely lead to violence.

No one can tell for sure what has caused a particular person's problems. The only way is to sit down with them and try and work it out.

Services should not insist that people see themselves as ill. Some prefer to think of their problems as, for example, an aspect of their personality which sometimes gets them into trouble but which they would not want to be without.

We need to invest much more in prevention by attending to inequality and child maltreatment. Concentrating resources only on treating existing problems is like mopping the floor while the tap is still running.

The finding that psychosis can be understood in the same way as other psychological problems such as anxiety is one of the most important of recent years, and services need to change accordingly. In the past we have often seen drugs as the most important form of treatment. Whilst they have a place, we now need to concentrate on helping each person to make sense of their experiences and find the support that works for them.

Thanks, Anne. I welcome your effort to clarify and destigmatize the confusing term "psychosis." I also heartily agree that it is crucial to attend to the psychological and emotional meaning of all experiences and understand the social context in which they occur.

But I do worry that your report creates its own set of unintended problems and may inadvertently perpetuate rather than dispel confusion and stigma, especially for those who have the most severely impairing of psychotic experiences.

The fundamental problem is that the report uses the term "psychosis" far too loosely and nonspecifically, lumping together very distinct situations that are better understood once they are teased apart diagnostically.

I can think of at least six distinct current usages of the word "psychosis," each of which has a quite significantly different implication regarding severity, chronicity, clinical significance, causality, and treatment:

"Psychosis" is often misleadingly misused to describe anyone who occasionally experiences hallucinations. This overlooks the fact that 10 percent of the general public reports having had a hallucination, and 20 percent reports having had a direct encounter with an angel or devil. We forget that some of the greatest leaders in history—including shamans, saints, artists, writers, and the founders of most religions—have hallucinated. If this loose usage of "psychosis" had been applied in the 15th century, Joan of Arc would been sidelined in a hospital and medicated instead of leading the French army to victory. Not every unusual experience is evidence of a mental disorder. "Psychosis" should be reserved only for those who are unable to reality-test the hallucination and also display significant distress and impairment in interpersonal and vocational functioning.

Brief psychosis is considered a mental disorder, but it is just a transient one with excellent prognosis and no reason to expect long-term impairment. The symptoms emerge suddenly in response to stress and usually disappear just as suddenly (especially if the stress is removed), often never to reappear. This is common in many cultures, and I have seen it fairly often in college students away from home for the first time, in travelers in strange lands, and in people who have had something terrible happen to them. Antipsychotic medicine is needed only briefly, if at all.

Psychosis may be caused by intoxication or withdrawal from alcohol, a medication, or a street drug. The symptoms usually go away promptly once the person is detoxed and as long as they stay off whatever they were taking. Antipsychotic medicine is again needed only briefly, if at all.

Psychoses arising from medical or neurological diseases often get better if and when the disease gets better. Antipsychotic medicine may be necessary in the short run, or if the illness is irreversible, but is often overused, particularly with the elderly in understaffed nursing homes, where it has the dreadful impact of reducing life expectancy.

Psychosis can occur (usually episodically) as part of bipolar and major depressive disorder, usually requiring short-term antipsychotic treatment, but continued long-term use is often not necessary.